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Impact of maternal undernutrition and childbearing in adolescence on offspring stunting

Summary of research1

Location: Global

What we know: Public policy change is needed to improve the nutrition status of populations globally; very little literature exists on what is necessary to enable nutrition policy change.

What this article adds: A recent review of existing systematic data examined enablers of and barriers to public nutrition policy change in high-income, democratic countries. Sixty-three studies were included on policy-making in public health nutrition in international, national, state and local settings. Two overarching themes were identified: political will (the extent to which decision-makers were supportive of policy change) and public will (the mood and policy preferences of voters). Barriers to policy change were the rise of neoliberal ideology; pressure from industry; lack of knowledge, skills and resources on the part of health advocates; and government silos. Enablers of policy change were developing a well thought-through solution; building relationships with key stakeholders; using emotions and values; being visible; engaging a policy entrepreneur; and understanding the policy-making process.

Improving the nutrition status of populations remains an urgent priority for both over and undernutrition. Recent papers advocate that the most effective way of achieving this is to promote and implement public policy change through regulation, legislation and public awareness campaigns to encourage healthy food choices (Roberto et al, 2015; Hawkes et al, 2015). However, changing public policy is slow and challenging due to process complexity and the conservative nature of political systems, which favour the status quo. For change to occur, the power of vested interests must be challenged and the policy problem, policy solution and political climate must align (True, Jones & Baumgartner, 1999; Kingdon, 1995). Limited peer-reviewed literature exists on effective advocacy strategies for in?uencing public health policy in general, with even less on in?uencing public health nutrition policy. This paper aims to fill this gap by considering real-world factors and practical experiences of past advocacy efforts to identify and synthesise barriers to and enablers of policy change in the field of nutrition in high-income, democratic countries.

The review reanalysed the results of a previous systematic literature review (Cullerton et al, 2015). Studies examining policy-making in public health nutrition in international, national, state and local settings in high-income democratic countries were identified and an interpretive synthesis was undertaken. A total of 63 studies were included.


Numerous topics were identi?ed under the theme of political will (whether decision-makers – politicians or senior bureaucrats – were supportive of policy change). A second major theme, public will, re?ects the mood and policy preferences of voters. Public will underpinned political will; politicians were often not motivated to act on an issue that had little public interest or could cause a backlash from wider society. Four barriers to policy change emerged:

Influence of neoliberal ideology: This involves the prioritisation of economic prosperity in policy decisions. Papers pinpointed a lack of support for regulatory intervention (which can interfere with market-driven economies) and concerns about the cost of implementing proposed solutions and monitoring compliance. This was problematic for many public health nutrition initiatives as evidence around cost-effectiveness did not exist or was dif?cult to determine due to the complexity and multifactorial nature of nutrition problems. Government policies that resulted in short-term economic bene?t were prioritised over policies related to longer-term health outcomes.

Pressure from industry: This came in various forms, including intense lobbying. Lobbyists are ever present and more vigilant than public interest groups (Dodson et al, 2009). Industry deliberately creates scienti?c uncertainty around issues, such as claiming insuf?cient evidence on effective interventions. Industry also influences cultural norms by investing considerable resources to control how nutrition problems and solutions are framed.

Limited resources, money and time of health advocates: Volunteer health advocates felt at a distinct disadvantage against full-time, paid lobbyists, having less time and money to directly lobby decision-makers and less understanding of policy and political processes. Often health advocates failed to communicate effectively with policy-makers; for example by providing reams of evidence or using complex language rather than concise, targeted communications.

Government silos: Government responsibility for dietary intake is spread across different government departments that work in ‘silos’ and prioritise their own objectives; this challenges coordination and effective advocacy interventions.

Enablers that improve the likelihood of positive policy change for improved nutrition were:

Well thought-through solutions: The most successful solutions had clear, costed strategies on how to solve the problem, single or incremental strategies and a local focus.

Build relationships with and gain support from a wide range of policy-makers and stakeholders: This can generate diverse and well-connected coalitions that strengthen the voice on an issue and provide a more powerful in?uence. Non-traditional alliances were useful in this respect; for example, agricultural and producer interests.

Use of emotions and values: While evidence is important, the use of stories and emotions to engage values can be compelling. The most effective framing relied on simple messages that were easy for the general public and politicians to grasp.

Visibility: To be effective, advocates must ?rst have their issue acknowledged by policy-makers as a problem worthy of attention. This requires high-level communication skills and creative solutions. Several studies found that attendance by policy-makers at a high-pro?le event or their reading of a key report triggered policy action. Frequent media engagement with the media and mobilisation of wider society was also important. Many studies highlighted the effectiveness of using a ‘policy entrepreneur’ (for example, a local government chief executive or politician) as a conduit for disseminating evidence to legislators and promoting recommended strategies. This also increased visibility and improved political will.

Understanding the policy-making process: The review found that solutions needed to be politically palatable by aligning to at least one goal of government and the prevailing ideology and decision-makers needed to be strategically targeted. Advocates needed to be ‘nimble’ by understanding how and when the processes of problem recognition, policy development and political decision-making converge to jump in the ‘policy window’. If all else fails, three papers identi?ed threatening corporations with litigation as a powerful, last-resort strategy.

There is a common belief that policy-making is a rational process in which evidence is used to assess the relative costs and bene?ts of options. However, evidence is only one component of in?uence; it also requires political and often public will for the proposed policy problem and solution. The suite of enablers presented in this paper can be used by public health professionals to influence political and public will in future advocacy efforts.


1Cullterton K, Donnet T, Lee A and Gallegos D. (2016). Playing the policy game: a review of the barriers to and enablers of nutrition policy change. Public Health Nutrition: 19(14), 2643–2653 doi:10.1017/S136898001600067


Cullerton K, Donnet T, Lee A et al. (2015) Using political science to progress public health nutrition: a systematic review. Public Health Nutr (Epublication ahead of print version).

Dodson EA, Fleming C, Boehmer TK et al. (2009) Preventing childhood obesity through state policy: qualitative assessment of enablers and barriers. J Public Health Policy 30, Suppl. 1, S161–S176.

Hawkes C, Smith TG, Jewell J et al. (2015) Smart food policies for obesity prevention. Lancet 385, 2410–2421.

Kingdon J (1995) Agendas, Alternatives, and Public Policies. New York: HarperCollins.

Roberto CA, Swinburn B, Hawkes C et al. (2015) Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking. Lancet 385, 2400–2409. 2.

True JL, Jones BD & Baumgartner FR (1999) Punctuated equilibrium theory: explaining stability and change in American policymaking. In Theories of the Policy Process, pp. 97–115 [P Sabatier, editor]. Boulder, CO: Westview Press. 4.

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Impact of maternal undernutrition and childbearing in adolescence on offspring stunting. Field Exchange 55, July 2017. p32.



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